Developmental Dysplasia       of the Hip
Overview Introduction Normal Development of the Hip Etiology and Pathoanatomy Epidemiology and Diagnosis Ultrasound m...
Introduction   Developmental Dysplasia of the Hip    • DDH - preferred term    • Teratogenic hips    • Subluxation    • D...
Background   Risk Factors    •   1/1,000 born with dislocated hip    •   10/10,000 born with subluxation or dysplasia    ...
Breech Presentation
Associated ConditionsTorticollis (15% have DDH)   Metatarsus Adductus                             (1.5-10%have DDH)
Normal Development   Embryonic    • 7th week - acetabulum and hip formed      from same mesenchymal cells    • 11th week ...
Normal Hip Tight fit of head in  acetabulum Transection of  capsule    • Still difficult to      dislocate    • Surface ...
Pathoanatomy Ranges from mild dysplasia --> frank  dislocation Bony changes    • Shallow acetabulum    • Typically on ac...
Pathoanatomy   Soft tissue changes    • Usually secondary to prolonged subluxation or      dislocation   Intraarticular ...
Fatty Tissue (Pulvinar Thickens)
Teres ligament (elongated and thickened)Docking the head
subluxated                       dislocated             Labrum: Cartilaginous acetabular lip.             Neolimbus: a rid...
Transverse ligament (hypertrophic)
Hourglass shape of the capsuleby the iliopsoas tendon
progressiveShortened of pelvifemoralmuscles
Pathoanatomy   Soft Tissue (Intraarticular)    • Transverse acetabular ligament         Contracted    • Limbus         ...
Tough Reductions…   Obstacles to    reduction    • Extraarticular          Tight iliopsoas and           adductors    • ...
Etiology and Epidemiology   Multifactorial    • Genetics and Syndromes        Ehler’s Danlos        Arthrogryposis     ...
Diagnosis   Newborn screening    • Ortolani’s and Barlow’s maneuvers with      a thorough history and physical    • Warm,...
Diagnosis   Key physical    findings    • Asymmetry          Limb length-           Galeazzi          Abduction ROM    ...
Ortolani’s Maneuver* After 3 months of age tests become negative
Barlow’s Maneuver
CLINICAL PRESENTATION          (THE NEONATE):Ortolani’s or Barlow’s sign Sonographic morphology.
CLINICAL PRESENTATION (THE NEONATE):
CLINICAL PRESENTATION(THE NEONATE):      Barlow           Ortolani               clunk
CLINICAL PRESENTATION (THE INFANT):    Limited Abduction    Galeazzi Sign                                         Hips    ...
CLINICAL PRESENTATION(THE INFANT):Asymmetric Folds
CLINICAL PRESENTATION (THE INFANT):recognize a.bilateral dislocation                                  Klisic Test         ...
CLINICAL PRESENTATION (THE WALKING CHILD):
Femoral Neck Anteversion
IMAGING STUDIES (ULTRASOUND)    identify   a silent hip
IMAGING STUDIES(ULTRASOUND)
IMAGING STUDIES (ULTRASOUND) BASELINE: line of ilium which intersects the bony and the cartilaginous portions of the aceta...
IMAGING STUDIES (ULTRASOUND)The Ultrasound ( before 3 mo. )  Ilium                           Abductor M.
IMAGING STUDIES (ULTRASOUND)
Diagnosis Some cases still missed At risk groups should be further  screened AAP    • Recs further imaging (e.g. US) if...
Imaging   X-rays    • Femoral head ossification center         4 -7 months   Ultrasound    • Operator dependent CT MR...
Imaging   Ultrasound    • Introduced in 1978 for eval of DDH    • Operator dependent    • Useful in confirming subluxatio...
UltrasoundFemoral headAbductorsIlium
UltrasoundFemoral headAbductorsIlium
UltrasoundFemoral headAbductorsIlium
UltrasoundFemoral headAbductorsIlium
UltrasoundGraf’s alphaangle
UltrasoundGraf’s alphaangle>60° = normal*line w/ iliumbisects head 50/50
Fig. 5-A:: Figs. 5-A, 5-B, and 5-C: Ultrasonography of the infant hip with use of thedynamic technique. (Figures kindly pr...
Fig. 5-B:: A transverse flexion ultrasonographic view of a normal hip showsthe femoral head (F) remaining in contact with ...
Fig. 5-C:: With instability and displacement, the femoral head moves laterallyand posteriorly. The laterally displaced hea...
Developmental Dysplasia of the Hip and Ultrasound
Developmental Dysplasia of the Hip and Ultrasound
Developmental Dysplasia of the Hip and Ultrasound
Developmental Dysplasia of the Hip and Ultrasound
Developmental Dysplasia of the Hip and Ultrasound
Developmental Dysplasia of the Hip and Ultrasound
Developmental Dysplasia of the Hip and Ultrasound
Developmental Dysplasia of the Hip and Ultrasound
Developmental Dysplasia of the Hip and Ultrasound
Developmental Dysplasia of the Hip and Ultrasound
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Developmental Dysplasia of the Hip and Ultrasound

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Developmental Dysplasia of the Hip and Ultrasound

  1. 1. Developmental Dysplasia of the Hip
  2. 2. Overview Introduction Normal Development of the Hip Etiology and Pathoanatomy Epidemiology and Diagnosis Ultrasound morphologic and dynamic
  3. 3. Introduction Developmental Dysplasia of the Hip • DDH - preferred term • Teratogenic hips • Subluxation • Dislocation-usually posterosuperior (reducible vs irreducible) • Dysplasia
  4. 4. Background Risk Factors • 1/1,000 born with dislocated hip • 10/10,000 born with subluxation or dysplasia • 80% Female • First born children • Family history (6% one affected child, 12% one affected parent, 36% one child + one parent) • Oligohydramnios • Breech (sustained hamstring forces) • Native Americans (swaddling cultures) • Left 60% (left occiput ant), Right 20%, both 20% • Torticollis or LE deformity
  5. 5. Breech Presentation
  6. 6. Associated ConditionsTorticollis (15% have DDH) Metatarsus Adductus (1.5-10%have DDH)
  7. 7. Normal Development Embryonic • 7th week - acetabulum and hip formed from same mesenchymal cells • 11th week - complete separation between the two • Prox fem ossific nucleus - 4-7 months
  8. 8. Normal Hip Tight fit of head in acetabulum Transection of capsule • Still difficult to dislocate • Surface tension
  9. 9. Pathoanatomy Ranges from mild dysplasia --> frank dislocation Bony changes • Shallow acetabulum • Typically on acetabular side • Femoral anteversion
  10. 10. Pathoanatomy Soft tissue changes • Usually secondary to prolonged subluxation or dislocation Intraarticular • Labrum  Inverted + adherent to capsule (closed reduction with inverted labrum assoc with increased Avascular Necrosis) • Ligamentum teres  Hypertrophied + lengthened • Pulvinar  Fibrofatty tissue migrating into acetabulum
  11. 11. Fatty Tissue (Pulvinar Thickens)
  12. 12. Teres ligament (elongated and thickened)Docking the head
  13. 13. subluxated dislocated Labrum: Cartilaginous acetabular lip. Neolimbus: a ridge of thickened articular cartilage
  14. 14. Transverse ligament (hypertrophic)
  15. 15. Hourglass shape of the capsuleby the iliopsoas tendon
  16. 16. progressiveShortened of pelvifemoralmuscles
  17. 17. Pathoanatomy Soft Tissue (Intraarticular) • Transverse acetabular ligament  Contracted • Limbus  Fibrous tissue formed from capsular tissue interposed between everted labrum and acetabular rim Extraarticular • Tight adductors (adductor longus) • Iliopsoas
  18. 18. Tough Reductions… Obstacles to reduction • Extraarticular  Tight iliopsoas and adductors • Intraarticular  Labrum  Ligamentum teres  Transverse acetabular ligament  Pulvinar  Redundant capsule (hourglass)  +/- limbus
  19. 19. Etiology and Epidemiology Multifactorial • Genetics and Syndromes  Ehler’s Danlos  Arthrogryposis  Larsen’s syndrome • Intrauterine environmental factors  Teratogens  Positioning (oligohydramnios) • Neurologic Disorders  Spina Bifida
  20. 20. Diagnosis Newborn screening • Ortolani’s and Barlow’s maneuvers with a thorough history and physical • Warm, quiet environment with removal of diaper • Head to toe exam to detect any associated conditons (Torticollis, Ligamentous Laxity etc.) • Baseline Neuro and Spine Exam
  21. 21. Diagnosis Key physical findings • Asymmetry  Limb length- Galeazzi  Abduction ROM  Skin folds  Limp  Waddilng gait / hyperlordosis - bilateral involvement
  22. 22. Ortolani’s Maneuver* After 3 months of age tests become negative
  23. 23. Barlow’s Maneuver
  24. 24. CLINICAL PRESENTATION (THE NEONATE):Ortolani’s or Barlow’s sign Sonographic morphology.
  25. 25. CLINICAL PRESENTATION (THE NEONATE):
  26. 26. CLINICAL PRESENTATION(THE NEONATE): Barlow Ortolani clunk
  27. 27. CLINICAL PRESENTATION (THE INFANT): Limited Abduction Galeazzi Sign Hips 90degrees
  28. 28. CLINICAL PRESENTATION(THE INFANT):Asymmetric Folds
  29. 29. CLINICAL PRESENTATION (THE INFANT):recognize a.bilateral dislocation Klisic Test Anterior superior iliac spine Greater trochanter Normal Dislocation
  30. 30. CLINICAL PRESENTATION (THE WALKING CHILD):
  31. 31. Femoral Neck Anteversion
  32. 32. IMAGING STUDIES (ULTRASOUND) identify a silent hip
  33. 33. IMAGING STUDIES(ULTRASOUND)
  34. 34. IMAGING STUDIES (ULTRASOUND) BASELINE: line of ilium which intersects the bony and the cartilaginous portions of the acetabulum.15-29 As the femoral head subluxates: decreased ALPHA angle increased BETA angle
  35. 35. IMAGING STUDIES (ULTRASOUND)The Ultrasound ( before 3 mo. ) Ilium Abductor M.
  36. 36. IMAGING STUDIES (ULTRASOUND)
  37. 37. Diagnosis Some cases still missed At risk groups should be further screened AAP • Recs further imaging (e.g. US) if exam is “inconclusive” AND  First degree relative + female  Breech  Positive provocative maneuver (Ortolani or Barlow) • Referral to Orthopaedist
  38. 38. Imaging X-rays • Femoral head ossification center  4 -7 months Ultrasound • Operator dependent CT MRI Arthrograms • Open vs closed reduction
  39. 39. Imaging Ultrasound • Introduced in 1978 for eval of DDH • Operator dependent • Useful in confirming subluxation, identifying dysplasia of cartilaginous acetabulum, documenting reducibility • Prox Femoral Ossification Center interferes • Requires a window in spica cast (avoid)
  40. 40. UltrasoundFemoral headAbductorsIlium
  41. 41. UltrasoundFemoral headAbductorsIlium
  42. 42. UltrasoundFemoral headAbductorsIlium
  43. 43. UltrasoundFemoral headAbductorsIlium
  44. 44. UltrasoundGraf’s alphaangle
  45. 45. UltrasoundGraf’s alphaangle>60° = normal*line w/ iliumbisects head 50/50
  46. 46. Fig. 5-A:: Figs. 5-A, 5-B, and 5-C: Ultrasonography of the infant hip with use of thedynamic technique. (Figures kindly provided by Prof. H. T. Harcke.)Fig. 5-A: Photograph showing the position of the transducer used to obtain thetransverse flexion view. With the hip in this position of flexion and adduction, a posteriorpush is analogous to the Barlow test.
  47. 47. Fig. 5-B:: A transverse flexion ultrasonographic view of a normal hip showsthe femoral head (F) remaining in contact with the ischium (arrows) duringmovement. A = anterior, L = lateral, and P = posterior.
  48. 48. Fig. 5-C:: With instability and displacement, the femoral head moves laterallyand posteriorly. The laterally displaced head (F, open arrows) has no contactwith the ischium (solid arrows). Fibrofatty tissue (T) with increased echogenicityfills the acetabulum. A = anterior, L = lateral, and P = posterior.

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